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2 ACKNOWLEDGEMENTS Swaziland Couples HIV Testing and Counseling Working Group: Phumzile Mndzebele Swaziland National AIDS Program Tengetile Kubheka PSI Makhosazana Dlamini PSI Mkhatshwa Lindiwe University Research Council Scelile Zwane National Emergency Response Council on HIV and AIDS Gcinile Nyoni University Research Council Thembie Masuku Elizabeth Glaser Pediatric AIDS Foundation Vijay Narayan CHAI Victoria Masuku PSI Lenhle Nsibandze Swaziland National AIDS Program Thembisile Dlamini UNAIDS Zandile Nhleko Elizabeth Glaser Pediatric AIDS Program Rwanda Zambia HIV Research Group (RZHRG) and Zambia Emory HIV Research Project (ZEHRP) Dr. Susan Allen, a Professor at Emory University, with her colleagues and field staff in Rwanda and Zambia, conducted the sentinel research that clearly documented the critical importance of couples HIV testing and counseling services. The counselors on these studies from the Rwanda-Zambia HIV Research Group (including Project San Francisco [PSF] in Kigali, Rwanda, and the Zambia-Emory HIV Research Project [ZEHRP] in Lusaka, Zambia) pioneered approaches to delivering HIV counseling and testing services to couples. Dr. Allen and her staff provided ongoing guidance and support throughout the conceptualization and consultation process of developing this curriculum. Dr. Allen s research has been supported by the US National Institutes of Health, including the Institutes of Allergy and Infectious Diseases, Mental Health, and Child Health and Development, as well as the International AIDS Vaccine Initiative (IAVI). Annie M. Mwaanga ZEHRP - Lusaka Jonathan Davitte ZEHRP - Ndola Staff Members: Muyunda M. Mulenga ZEHRP Ndola 2

3 INTRODUCTION The Couples HIV Testing and Counseling (CHTC) Intervention and Training Curriculum was developed in response to increased demand from field partners for interventions and training that would help them address the complex issues related to HIV testing and counseling (HCT) with couples. The materials are intended to guide trainers and participants through a general course covering essential topics and activities for the CHTC provider. By addressing CHTC technical content, and counseling and communication skills through learning exercises and hands-on practice, the materials aim to increase the skills of counselors who provide HCT to couples. Working with couples can be challenging and complex, even for the most experienced counselor. This manual was developed to address the challenges faced by these counselors in the field. The goal of this manual is to guide trainers in training HIV prevention counselors to conduct CHTC sessions. The chapters outlined in the curriculum will build upon the existing counseling skills of HCT providers so that they may help individuals in a couple understand the results of their HIV tests, as well as the importance of preventing all of their partners from becoming infected with HIV. CHTC has emerged as an important intervention aimed at preventing the transmission of HIV between sex partners, and cohabiting or married couples. HIV prevention counselors can assist couples by: 1. Providing clear and accurate prevention messages tailored to the couple s life stage and reasons for seeking HCT services 2. Mitigating tension and diffusing blame 3. Dispelling myths about HIV transmission 4. Creating an environment that is safe for disclosure of HIV status among partners; and 5. Discussing options for disclosure of HIV status to the couple s children, and thinking through appropriate next steps for testing children, when necessary. Swaziland has policies and HCT guidelines supporting and promoting CHTC. CHTC is provided in all public and private health facilities. 3

5 INTRODUCTORY LESSON This section will introduce the goals of this training and explain the importance of the couples HIV testing and counseling (CHTC) model. In addition to talking about expectations for the training as a whole, participants will also discuss the following topics: Goals of couples HIV testing and counseling Comparison of CHTC with other HIV testing approaches in Swaziland The concept of discordance This section will also include some get-to-know-you activities and a Pre-Course Knowledge Assessment. HIV Couples Testing and counseling: Facilitating a Shared Vision In many parts of the world, people speak their own regional language and one other widely shared language. Couples counseling is a variation of this. In couples counseling there are four views: those of each partner, the couple together, and the counselor. In HIV couples testing and counseling, the goal is to bring together these views and to create a shared vision and a shared language. This shared vision is the couple s acceptance of the realities of HIV in their lives, being empowered to prevent acquiring and transmitting HIV, and sharing their support and compassion for each other. Over the next few days, we will cover many aspects of counseling couples. Our goal is that you understand all the aspects of couples HIV testing and counseling. We ll begin with the importance of couples counseling and discuss the skills you will need to counsel couples and the unique characteristics of counseling couples in different life stages. 5

6 Goal of the Training Course The goal of this course is to train people who provide HIV counseling and testing services to individuals on how to conduct an HIV prevention counseling session with couples by following the Couples HIV Testing and Counseling (CHTC) Protocol. Objectives for the Training Course By the end of this course, the participants will understand the following concepts and develop counseling skills in their application: Importance of couples HIV testing and counseling Counseling skills required to work effectively with couples Unique HIV counseling and testing issues of couples at different life stages Components of CHTC Protocol Effectively communicating the concept of HIV sero-discordance to couples Multiple approaches to recruit and conduct outreach to couples Appropriate support services for couples 6

7 CHAPTER ONE: WHY CHTC IN SWAZILAND? APPROACHES TO HIV TESTING AND COUNSELING (HCT) SERVICES Client-Initiated HTC Approach In the CIHTC approach; traditionally known as VCT, an individual voluntarily seeks HIV testing and counselling at a site providing this service. This approach emphasizes individual risk assessment and management by counsellors, addressing issues such as the desirability and implications of taking an HIV test and the development of an individualized risk reduction plan. In Swaziland, CIHTC is conducted in different settings including those detailed below: Stand alone or free-standing sites These are sites situated outside health facilities with HTC services being mainly provided by Non Governmental Organizations (NGOs), Community Based Organizations (CBOs) and other sectors such as the private sector Integrated sites In these sites, HTC services are integrated or co-located within the health care system in hospitals, health centres, clinics and public health units within government and non-governmental facilities which include the private sector. Mobile and Outreach Services The HTC services are provided from fully equipped mobile caravans/vehicles and other movable structures such as tents that are designed to provide HTC services to whichever locations and settings as are deemed convenient and accessible to the target populations. HTC outreach services should be provided as an extension of existing and established workstation, stand alone and/or integrated sites at workplaces and in the communities during community gatherings, mass testing events and national HTC campaigns. Home Based HTC through door to door Services HTC services will be provided in a home setting and will have a family focus in order to increase the access and uptake of HTC services by entire families, couples and individual family members. Door to door service can only be provided by counsellors/ organizations with presence in that community and from a fixed site/work station. This model will ensure follow up care, tracking of referrals and disclosure counselling. Provider-Initiated HTC Approach In the PIHTC approach, HTC is routinely offered by health care providers to persons attending health care facilities as part of normal standard of care. HTC should be offered regardless of whether the person shows signs and symptoms of underlying HIV infection or of the person s reasons for presenting to the health facility. The major purpose of such testing and counselling is to enable specific clinical decisions to be made and/or specific medical services to be offered that would not be possible 7

8 without knowledge of the person s HIV status. PIHTC should be made available in different facilities, settings and services including but not limited to inpatients, general and outpatient departments specialized clinics such as, TB, STI services, ANC, Family Planning, child welfare, Male Circumcision and Home Based HTC through index client. Routine Offer of HIV Testing Routine offer of HIV testing by health care workers should be made to all patients/clients and their partners who attend health care facilities but not limited to; In-patient and outpatient facilities Hospital in-patient wards usually have a high concentration of persons with presumptive HIV who would benefit from diagnosis, treatment and care. Because not everyone with severe HIV-associated immunodeficiency has obvious clinical symptoms or signs of disease, HTC should be routinely offered to all persons admitted to hospitals and other in-patient facilities. This approach can be utilized to increase access to HTC by relatives of admitted patients. Although outpatients are generally less ill than inpatients, HTC should also be routinely offered to all persons attending out-patient health facilities. Tuberculosis (TB) clinics TB is the most common condition associated with HIV infection. According to the 10 th ANC Sentinel Surveillance Report, 80% of TB patients in Swaziland were coinfected with HIV. This high TB and HIV co-infection rate provides an opportunity for identifying individuals with HIV among TB patients and those with TB among HIV positive patients. Therefore, it is imperative that all TB patients are offered HIV testing and all HIV positive clients have access to TB screening services. Sexually Transmitted Infection (STI) services In Swaziland, sexual intercourse is the primary mode of transmission for HIV infection. Accordingly, HTC should be routinely offered to all persons presenting at STI or sexual health services, or who present at other types of health services with an STI. Antenatal, delivery and postpartum health services In 2008 the HIV prevalence in the antenatal population was 42%. Therefore HTC must be offered to all women of unknown HIV status during pregnancy, in labor, as soon as possible after delivery or in the postpartum period. Knowledge of HIV status enables HIV positive women to receive HIV-related services for themselves and their infants, including infant feeding counselling and support and diagnosis of the infant. It also allows for reinforcement of prevention counselling for HIV negative women, and serves as an entry point for partner HTC. Family planning (FP) services Women attending these services are more likely to make better decisions about their reproductive health if they have knowledge of their HIV status. FP does not offer HIV prevention benefits and dual contraception should be encouraged with promotion of HTC services in this context. 8

9 Child Welfare services Routine testing of all exposed infants should be offered within the child welfare clinic at the six week visit or the child s first contact with the system. Home based HTC services through index clients As part of the scale up of access to HTC, PIHCT services will be provided through index client-linked home based services within communities. In this model, counsellors providing follow up care to their index client and tracking referrals will take the opportunity provided to reach couples and families with comprehensive HIV prevention messages and an offer of HTC services. National Blood Transfusion Service In order to ensure that Swaziland maintains a safe blood supply, all persons donating blood must be offered HTC. Those donors testing positive should be referred to appropriate care and treatment follow-up services. Male circumcision Routine HIV testing for all males seeking male circumcision service In the Swaziland context of a generalized epidemic, people who are infected with HIV come from all segments of society irrespective of age, sex, socio-economic status, education, marital status, or religious affiliation. Therefore there is an urgent need to maximize access to knowledge of one s HIV status towards achieving universal access to HIV prevention, treatment, care, and support by combining the different approaches described above and targeting all the different entry points to testing. The focus of this training is couples HIV testing and counseling (CHTC). Couples testing and counseling can be delivered in different settings and must be implemented at all the different entry points through PIHTC or CIHTC. TYPES OF COUPLES SEEKING HIV TESTING AND COUNSELING SERVICES Pre-sexual Couples Pre-sexual couples may be using CHTC to decide whether to pursue a long-term relationship based on their test results. This is a prudent course of action, and the couple should be commended for their commitment to acting responsibly and getting tested. However, it presents the counselor with some challenges. If the couple is discordant, it s possible the relationship will dissolve. Also, the HIV-positive partner may be concerned about confidentiality and whether the HIV-negative partner will disclose the test results. Therefore, the counseling session may focus on how the couple will supportively manage changing the course of their relationship. Sexual Couples Sexual couples are those who are in an association involving sexual intimacy. The sexual contact may be regular or sporadic, occurring over a period of time. These may be couples who may not necessarily be a steady, exclusive relationship, but may be termed as friends with benefits or shag buddies, etc. They may be using 9

10 CHTC services in order to decide whether to commit to the relationship. It is highly likely that discordant couples who are in this kind of liaison will go their separate ways after learning of their HIV status. Engaged Couples Engaged couples have often been recognized publicly by family and friends as in a serious relationship. Elaborate plans for a wedding may have been made. There are numerous confidentiality and disclosure implications if the couple decides to alter their plans based on their test results. Discordant, engaged couples may have difficulty continuing their relationship. However, it may be quite difficult for the couple to initially acknowledge this, since emotions at this point in a relationship are very intense. The partners may make testimonials to their commitment and the power of their love. Young couples receiving concordant positive results are faced with difficult psychological and interpersonal challenges at a time in their lives when they thought their future was full of dreams and promise. Many engaged couples have limited skills and experience in dealing with stressful and difficult circumstances as a couple. Married or Cohabitating Couples Couples that are married or cohabitating generally define their lives collectively, as a partnership. They may be more interdependent socially, financially, and emotionally. Married or cohabitating couples may have more skills and experience coping together with problems. However, these couples may also have pre-existing conflicts and issues in their relationship that impede their communication and their ability to work together to address HIV issues in their lives. Polygamous Couples Polygamous couples have many complex dynamics. The wives may not be equal partners with the husband. If all partners are receiving CHTC together, the dynamics may be challenging. If only one wife is present, there are significant implications for the absent wife or wives who are also affected by the counseling session and the test results. Reuniting Couples For reuniting couples, the circumstances behind their separation may influence the dynamics of the CHTC session and have a substantial impact on the partners ability to deal with their test results. Couples who separate because of marital discord often have struggled with issues of trust, faithfulness, and communication. If the couple has not addressed these issues before reuniting and seeking CHTC services, it may be difficult for the partners to deal supportively with concordant positive or discordant test results. In other instances, the couple may have been separated for a long time because of employment, educational opportunities, or family responsibilities. When working with reuniting couples, the counselor may want to facilitate the partners acknowledge of the existence of past issues and that their time apart may have had both benefits and potential risks. The counselor should keep the couple focused on the present and future. 10

11 BENEFITS OF COUPLES HIV TESTING AND COUNSELING 1. Couples counseling creates a safe environment for a couple to discuss risk concerns. 2. Partners can hear information and messages together, enhancing the likelihood of a shared understanding. 3. Couples counseling can help ease tension and diffuse blame. 4. Counseling messages are based on the results of both individuals. 5. Individual is not burdened with the need to disclose results and persuade partner to be tested. 6. Couples counseling facilitates the communication and cooperation required for risk reduction. 7. Couples counseling enables treatment and care decisions to be made together. 8. Couples are empowered to engage together in decision-making for the future. WHY DO WE NEED COUPLES HIV TESTING AND COUNSELING IN SWAZILAND? The couple is a collective unit representing more than two individuals ( our family or our life ). HIV/AIDS is a disease of the family, the community, and society. The couple is the backbone of the community. CHTC enables both partners to contend together with HIV, and plan for their future CHTC enhance opportunities to prevent mother-to-child transmission (MTCT) of HIV. CHTC can enhance opportunities to link the partners to prevention, care, treatment, and support services CHTC enables identification of discordance and helps the negative partner remain un-infected. CHTC also helps overcome the common misconceptions and myths about discordance: Many people believe discordance is not possible. When tested individually, many people assume that their partner s HIV status is the same as their own. Many people believe discordance is a sure sign of infidelity. 11

12 Unlike individual HTC, CHTC prevents automatic assumptions about partner s HIV status. CHTC promotes disclosure, which is critical given that individual rates of disclosure are so low DISCUSSING DISCORDANCE WITH COUPLES It is important to understand the different types of HIV test results that are possible during a couples counseling session. Sero-Discordance A concordant couple is one where both partners have the same HIV status they are both negative or both positive. A discordant couple has one HIVpositive partner and one HIV-negative partner. Discordance is common in countries with high prevalence of HIV. The percentages of couples who are concordant negative, concordant positive, and discordant will vary by the prevalence of HIV in the country, within communities in a country, and by service settings within communities, such as those in urban or rural settings, PMTCT settings, VCT centers, and TB clinics, among others. Communities with high HIV prevalence rates have higher rates of concordant positive and discordant couples. For example, we will look at the sero-status of couples from Zambia s 2007 DHS. From the 2007 DHS survey, we can see that 81% of cohabiting couples were concordant negative, 8% were concordant positive, and 12% were discordant. 12

13 HIV Prevalence among Cohabiting Partners Zambia, DHS 2007 In CHTC it will be very important for you to emphasize and explain areas that are not widely understood, such as couple discordance. The HIV-negative partners in discordant couples are at very high risk for getting HIV if the couple does not take steps to protect the HIV-negative partner. We will talk more about discordance in Chapter Four when we review that section of the CHTC intervention. Many people do not understand the facts about discordance. Many myths about discordance exist that need to be corrected. It is important that counselors make sure that discordant couples understand the facts about discordance: Facts about Discordance Couples can remain discordant for a long time even more than 10 years. In many cases, the couple enters the relationship when they are already discordant discordance is NOT a sure sign of infidelity. The negative partner in a discordant couple is not protected only by remaining faithful. Couples need to take precautions such as using condoms to prevent transmission from the infected partner to the negative partner. When couples are discordant, infection could have occurred in different ways: - The positive partner may have been infected before they became a couple. - The positive partner may have other partners outside the relationship or may have acquired HIV non-sexually. Transmission risk through sex is extremely high among steady discordant couples who do not take preventive measures such as using condoms. Again, transmission risk is extremely high in steady discordant relationships. CHTC helps reduce transmission among discordant couples by helping couples adopt riskreduction behaviors, increase condom use, and reduce mother-to-child transmission. 13

14 Consider the following study, which gives an idea of the impact you can have with partners in a discordant relationship by counseling them to change risk behaviors: Imagine 100 HIV-negative partners in discordant couples. Within 1 year, an average of 22 of these 100 HIV-negative partners will become infected unless they change their risk behaviors. This rate of transmission is higher than the transmission rates of TB or malaria. However, in this study of couple counseling, the majority of discordant couples changed their behavior and only 6 of 100 became infected within 1 year, suggesting that 16 infections were prevented. (Reference: Allen 1992) CHAPTER ONE: TAKE-HOME MESSAGES CHTC is critical because: Partners in a couple undergo testing and counseling together and learn the test results together. Partners hear prevention messages together and are guided by the counselor to think through both their HIV test results and to plan ways for ensuring a healthy future. Before knowing their HIV status, many discordant couples do not use condoms. However, CHTC has been shown to increase condom use. CHTC is equally beneficial for concordant positive and concordant negative couples. Concordant negative couples can take steps to protect their relationship from HIV, such as by being faithful to each other. Concordant positive partners can be supportive of each other and make decisions together regarding their HIV care and treatment and their future. 14

15 CHAPTER TWO: COUPLES COUNSELING SKILLS INTRODUCTION This chapter introduces counseling skills specific to working with couples. Throughout the training, these general couples counseling skills will be adapted to a couples HIV testing and counseling session. These skills include: Understanding how personal awareness can help a counselor prevent personal issues from influencing his or her interaction with couples during counseling Learning about the importance of forming alliances during a couples HIV counseling Directing communication from the counselor to the couple and from each member of the couple to each other Developing mediation skills to help couples ease tension and diffuse blame during the CHTC session Chapter Two examines these and several other skills and attributes specific to couples HIV testing and counseling. BASIC COUNSELING SKILLS Briefly review the basic counseling skills: Attending Attending is the use of physical behaviors such as smiling, leaning forward, making eye contact, gesturing, and nodding to convey to clients that the counselor is interested in and open to them. Open-ended and probing questions Open-ended and probing questions invite more than one or two word responses. These can be used to gather information, increase clarity, stimulate thinking, or create discussion. Empathizing Empathy means placing yourself in the client s situation while remaining objective. Empathizing requires the counselor to not be judgmental and to be sensitive and understanding. Paraphrasing Paraphrasing means the counselor uses different words to restate in a nonjudgmental way what the client has said. This is intended to help the client to know that the counselor is aware of the client s perspective and has heard what he or she has said. Paraphrasing and restating also allows the client to correct any misunderstanding on the part of the counselor. 15

16 Reflective listening Reflective listening involves repeating what a client has said, paraphrasing, displaying empathy, and reflecting back verbal and nonverbal feelings. For example, saying, So you feel or It sounds like you ensures the counselor understands what the client has said. SPECIFIC COUPLES COUNSELING SKILLS AND ATTRIBUTES Couples counseling is different from working with individuals in the approach that the counselor takes and in the techniques the counselor uses. The following are five skills or attributes that couples counselors need to keep in mind in order to work successfully with couples: (Source: Hardy 2002) 1. Counselor self-awareness Counselors should be aware of their own beliefs, biases, feelings, perceptions, and reactions and how their perspectives may affect the counseling session. The counselor who is in tune with personal attitudes, biases, and emotions has the ability to gauge his or her responses to the couple. Self-awareness also allows the counselor to provide unbiased empathy, understanding, and support to the couple. This is important, and we will be discussing the issue of self-awareness in detail. 2. Capacity to tolerate intensity Couple relationships are dynamic and complex, and HIV-related issues may be emotionally intense. The counselor must be able to tolerate this intensity while maintaining a consistent and supportive stance with the couple. The counselor will need to facilitate conversation and encourage the couple to deal with challenging issues. The couple s confidence in the counselor s ability to manage the session enhances their ability to relate to and deal with important issues. In both individual and couples counseling, the counselor must be able to tolerate strong emotions and feelings. However, in CHTC, the situation is more dynamic and complex because the counselor is dealing with two individuals who have a relationship with each other. A counselor s capacity to tolerate intensity is a skill often acquired over time and with experience and maturity. 3. Ability to both validate and challenge The counselor must have the ability to validate the couple s feelings and perceptions. At the same time, the counselor must challenge the couple to address the realities of HIV in their lives and their community. The counselor must also encourage the couple to take action to reduce the transmission of HIV. 4. Recognition that relationships are full of contradictions The couple s counselor must understand the couple s strengths and weaknesses. For example, the counselor should acknowledge the wish of the couple to preserve the relationship even while they struggle to accept the behavior changes required to protect one another. Engaging in behaviors that increase the risk of HIV transmission may be both pleasurable and painful. 16

17 5. Understanding relationships in the context of cultural values and norms Culture, gender dynamics, religious background, and economic status shape a couple s relationships. The counselor must understand and recognize that these dynamics exist while respectfully engaging both partners in the session and valuing equality and human dignity. 6. Understanding perceptions and concerns about the difficulties and challenges of working with CHTC Counselors may imagine consequences for couples that are far worse than the reality of how couples handle HIV results and disclosure. For example; research suggests: In general, disclosure has not been associated with the break-up of marriages. (Sources: Maman 2003, Kamenga 1991, Nebie 2001) Less than 15% of discordant couples initially experience psychological distress. (Source: Kamenga 1991) Less than 5% of stable couples separate or divorce after disclosure of an HIV positive test result. Among these couples, in most instances, follow-up counseling services can ease tension, diffuse blame, and promote reconciliation. (Sources: Maman 2003, Kamenga 1991, Nebie 2001) Less than 5% of stable couples experience violence as a result of receiving CHTC services together. 7. Customer Care general attitudes for patient-friendly services Counselors should be able to create a patient-friendly atmosphere despite beliefs, biases, feelings, perceptions, and reactions to the various types of couples that will be accessing CHTC services. SELF-AWARENESS EXERCISE Counselor self-awareness is a general term that refers to being able to understand how personal beliefs and experiences affect how a counselor reacts and responds in a counseling session. Personal biases can influence a counselor s ability to provide high-quality services to couples. Counselors regularly need to examine their own issues and hone their counseling skills to prevent their personal biases from interfering with their counseling sessions. This understanding is crucial for providing the highest quality of services to couples. 17

18 1. What are some examples of personal issues that may influence how you interact with your clients? 2. How can you prevent these issues from negatively influencing counseling sessions? 18

19 THE IMPORTANCE OF COUNSELOR SELF-AWARENESS Having high self-awareness allows counselors to: Provide high-quality services to all couples Ensure their values, beliefs, and experiences do not influence their interaction with couples. In other words, self-awareness helps the counselor remain nonjudgmental. Reduce the potential for biasing the couple s decisions Understand that he or she is not responsible for the test results or the couple s relationship Hear and understand the couple s concerns Offer genuine empathy and support Skillfully and effectively manage the couples counseling session Empower the couple NB: Consequently, through self-awareness, counselors are able to focus unbiased attention on the couple and effectively engage and empower the couple. OTHER ISSUES THAT MAY INFLUENCE THE COUNSELOR S ABILITY TO PROVIDE QUALITY SERVICES TO COUPLES Counselors should be aware of other issues when working with couples. Many of these issues are related to counselor self-awareness. They include: The counselor s experience, values, and feelings relating to couple relationships, including gender roles and expectations from the culture the counselor was raised in/lives in Dreams and aspirations the counselor has for his or her relationship, family, and future Counselor s relationship with his or her partner Counselor s experience receiving individual HIV testing and counseling services Counselor s willingness to receive couples HIV testing and counseling services Counselor s feelings about whether or not to disclose his or her HIV test result to partner Partner s reaction if counselor did disclose and the impact on their relationship ADDITIONAL COUPLES COUNSELING SKILLS The following counseling skills will help maintain a positive atmosphere and balanced couples interactions during the CHTC session. 19

20 Demonstrate neutrality and nonbiased concern for both members of the couple. Convey respect for the couple s relationship. Facilitate balanced participation of both partners during the session. Model appropriate listening and communication skills. Facilitate dialogue between members of the couple. Raise difficult issues that the couple may need to address. Ease tension and diffuse blame. FORMING AN ALLIANCE BETWEEN THE COUNSELOR AND COUPLE The counselor s first task is to build an alliance, or a partnership, with the couple. This alliance serves as the foundation that permits the couple to engage in the session and to be willing to discuss HIV-related issues. The first step in forming an alliance is offering a genuine attitude that conveys warmth and compassion. (Source: Keim 2002) The acronym A.C.E. explains three important elements of an alliance. Acknowledgment Describes the couple s awareness that the counselor acknowledges their strengths, courage, and experience. Competence The couple senses that the counselor has the skills and experience to guide and support them through the CHTC process. Empathy The counselor genuinely understands and appreciates the couple s experience and feelings. 20

Couples HIV Counseling and Testing Module Six will clarify the implications of discordance and will explain the Couples HIV Counseling and Testing (CHCT) procedure for counseling discordant couples, including:

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